Chemotherapy for Breast Cancer

Chemotherapy involves the use of chemicals that weaken or kill cancer cells and it's a mainstay of treatment for some types of breast cancer. This kind of treatment has long been associated with severe side effects, and while side effects are a reality of chemo, doctors have learned a lot about how to minimize them while also improving survival rates.

Whether your oncologist recommends chemotherapy for you depends on several factors.

Chemotherapy works by interfering with the ability of rapidly growing cells (like cancer cells) to divide or multiply. These powerful drugs kill or delay the growth of cancer cells by disrupting their DNA or protein production, preventing cell division, starving them of nutrients, or blocking hormone receptors.

Because most of an adult's normal cells are not actively dividing or multiplying, they aren't affected by chemotherapy. However, the bone marrow (where your blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing. The side effects of chemotherapy drugs are related to its effects on these and other normal tissues.

Chemotherapy is a systemic treatment, as opposed to a targeted treatment like surgery or radiation.

Not everyone with breast cancer needs chemotherapy. It's used in four specific instances.

1. After Surgery for Early-Stage Breast Cancer

This is called adjuvant chemotherapy, which means that it follows the primary treatment. It's intended to kill any cancer cells that may be left in your body after surgical removal of a tumor, but can't be seen on imaging tests. If left alone, these cells could grow into new tumors. Adjuvant chemotherapy lowers your risk of recurrence.

Typically for early-stage breast cancer, chemotherapy is reserved for those with a high risk of cancer recurrence or metastasis (spreading to other areas of the body), such as when cancer cells have spread to the lymph nodes in the armpit. Hormone therapy may be an alternative option in these cases.

2. Before Surgery for Early-Stage Breast Cancer

Called neoadjuvant chemotherapy, meaning it comes before the primary treatment, this is done to shrink tumors so they're easier to take out, sometimes because the tumor is too large to completely remove. In some cases, it may allow for a lumpectomy instead of a mastectomy. It can also eliminate cancer cells from some lymph nodes so fewer of them need to be removed. Like adjuvant chemotherapy, it may also kill cancer cells that have spread and it reduces the risk of recurrence.

Neoadjuvant chemo is common for:

• Inflammatory breast cancer
• HER2-positive breast cancer
• Triple-negative breast cancer
• High-grade tumors
• Large tumors
• Cancers that have spread to the lymph nodes

3. Advanced Breast Cancer Treatment

Chemotherapy is the main treatment for breast cancers that have metastasized (spread) beyond the breast and nearby lymph nodes because targeted treatments such as surgery are no longer adequate. The main goal in advanced cases is to lengthen and improve the quality of life, not to cure the disease.

4. Breast Cancer Prevention

In people who are at especially high risk of developing breast cancer, chemotherapy can be done to reduce their risk. This is called chemoprevention. Because of the risks associated with chemotherapy drugs, this is a step to be carefully considered with your doctor.

Many drugs and regimens (combinations of drugs) are used to fight breast cancer.

The most common ones for adjuvant and neoadjuvant therapy include:

• 5-FU (5-fluorouracil)
• Anthracyclines, including Adriamycin (doxorubicin) and Ellence (epirubicin)
• Cytoxan (cyclophosphamide)
• Paraplatin (carboplatin)
• Taxanes, including Taxol (paclitaxel) and Taxotere (docetaxel)

The most common chemo drugs for advanced breast cancer include:

• Anthracyclines, including Adriamycin (doxorubicin), Ellence (epirubicin), and pegylated liposomal doxorubicin
• Gezmar (gemcitabine)
• Halaven (eribulin)
• Ixempra (ixabepilone)
• Navelbine (vinorelbine)
• Platinum agents (cisplatin, carboplatin)
• Taxanes, including Taxol (paclitaxel), Taxotere (docetaxel), and Abraxane (albumin-bound paclitaxel)
• Xeloda (capecitabine)

How Chemotherapy is Given

Many chemotherapy drugs for breast cancer are given in liquid form, as intravenous infusions or injections, but some are available as pills or tablets. Some drugs may be given alone, and other drugs are combined to work together. When chemo drugs are given in combination, the treatment is called a regimen.

Some of the common regimens are:

• CMF: Cytoxan, methotrexate, and 5-FU
• AC: Adriamycin (doxorubicin) and Cytoxan
• CAF or FAC: Cytoxan, Adriamycin, and 5-FU
• CEF or FEC: Cytoxan, Ellence (epirubicin), and 5-FU
• TC: Taxotere (docetaxel) and Cytoxan

Typically, chemo is given once every three weeks, and you will need the intervening time to recover your blood counts and allow the drugs to work. Low-dose chemo is given weekly, as a smaller dose of drugs will require less recovery time. Oral chemo can be taken daily, or as directed. Injections may be given before, during, or after a chemo infusion.

Chemotherapy for early-stage breast cancer is generally given for about six months. If you're getting infusions, you'll need to budget more time away from work or other activities than just what's needed for infusion sessions.

Before each treatment, your medical oncologist may want you to take medications to protect against side effects. Be sure to take these on time and as prescribed.

On the day of your infusion, plan on about four hours in the clinic. Your blood will be drawn and a complete blood count will be done. All your vital signs and weight will be taken, as that determines the amount of your dose of chemo drugs for that day.

Your oncologist will review your blood counts and, if they're all in the proper range, you will proceed to the infusion room for your chemotherapy treatment.

A Weekly Chemo Schedule

If you're receiving weekly lower-dose chemo, such as Taxol, you will receive a smaller dose than the typical dose given every three weeks. The smaller dose will usually be infused every week for 12 weeks straight. This will add up to more overall chemotherapy than you would receive on a standard schedule. You may also be given a white blood cell booster shot between infusion sessions.

The Day After Chemo

At least one day after each chemotherapy infusion, your blood will be drawn and counted. If your red counts or neutrophils are low, you may be offered shots to boost those counts. Chemotherapy can greatly affect your blood counts because blood cells divide and multiply quickly and are therefore targeted by the drugs.

Do not miss these extra appointments! They're essential for recovering from chemo with a healthy immune system and avoiding anemia and neutropenia.

Sample Treatment Sequence

Here's a look at how chemotherapy appointments are typically scheduled:

• Day Before: Take pre-chemotherapy medications (if prescribed) to prevent side effects.
• Day 1: Blood draw, weigh-in, vital signs, check-up, chemo infusion
• Day 2: Shots to boost blood counts if needed
• Day 3 and Until Next Cycle: Rest and recovery

The powerful nature of chemo treatment is both its strength and the reason for its bad reputation for side effects. Remember that chemo targets all rapidly growing cells, and, in addition to cancer, that includes cells in your blood, digestive-tract mucous tissues, fingernails and toenails, and hair follicles. These effects will subside after you've finished treatment.

Common side effects include:

• Hair loss
• Nail changes
• Mouth sores
• Loss of appetite
• Weight changes
• Nausea and vomiting
• Diarrhea
• Increased chance of infection
• Easy bruising
• Easy bleeding
• Fatigue
• Nerve damage
• "Chemo brain" (memory and concentration problems)

Your specific chemotherapy drug or regimen may cause other side effects, as well.

Between chemotherapy appointments, if you have trouble dealing with side effects, don't hesitate to call your clinic and ask for help. If you're dehydrated after a treatment, you can ask for an infusion of saline fluid. Other medications may be given along with the saline, to help with nausea and vomiting.

Your chemotherapy nurses should know a lot of hacks for coping with side effects, so be sure to ask them for help, even if you don't have a scheduled appointment. Write down your symptoms—along with duration, severity, and how often they occur—before you call. That'll help them suggest ways to make you feel better.

Chemo also carries a risk of long-term side effects. You may need to be monitored for these in the years to come:

• Loss of bone mass (osteopenia and osteoporosis): Hormone-blocking chemotherapy drugs can cause early menopause, and that leads to an elevated risk of bone thinning conditions. Bone density tests and treatment may be necessary.
• Heart damage: Chemotherapy has a small risk of weakening the heart muscle or causing other problems with the heart.
• Leukemia (cancer of the blood cells): This side effect is rare but possible and usually occurs years after chemo is completed.

Fertility

Because specific chemo drugs can trigger medical menopause (which can be temporary or permanent) in premenopausal women, they can cause infertility.

If you have any thoughts about future pregnancies, let your oncologist know before you start treatment and ask what your options are. Depending on your age, drug regimen, and dosage, your fertility may return after treatment. However, if there's a chance that you'll become infertile, you need to know before your first chemo infusion.